Accreditation Manager

Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care.   

It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater. Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do — in the health of our patients, our loved ones, and our community.

Benefits Eligible

Full-Time Benefit Eligible

Work Shift

Day - 8 Hour or less Shift (United States of America)

Department

8750 Quality & Patient Safety

The Accreditation Manager is responsible for leading the organization’s regulatory and accreditation compliance efforts, ensuring continuous readiness for The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), California Department of Public Health (CDPH), and other regulatory agencies. This position serves as a regulatory expert, overseeing survey readiness, incident management, process improvements, policy development, and leadership collaboration to maintain a culture of compliance and patient safety.

QUALIFICATIONS

License /Certification

Required: California Registered Nurse (RN) license
Preferred: Certification in Healthcare Accreditation (HACP) and/or Certified Professional in Healthcare Quality (CPHQ)

Education
Required: Bachelor's degree in Nursing, related field or equivalent experience 
Preferred:  Master’s degree in Nursing or related field 

Experience
Required:

Minimum of three years of experience in acute care regulatory compliance, accreditation, or healthcare quality.
Experience in survey readiness, policy development, and process improvement.

Knowledge/Skills/Abilities
In-depth knowledge of TJC, CMS, CDPH, and other applicable regulatory standards.
Strong leadership, project management, and problem-solving skills.
Excellent communication and collaboration skills with the ability to engage multidisciplinary teams.
 

JOB RESPONSIBILITIES

Essential

Leads continuous readiness efforts for TJC, CMS, CDPH, and other agencies, including tracers, audits, evidence preparation, and regulatory program oversight.

Serves as a subject matter expert on accreditation and regulatory standards, interpreting requirements and guiding leadership and frontline teams.

Manages survey operations and command center activities during regulatory visits, ensuring real-time documentation, coordination, and executive briefings.

Develops, implements, and standardizes policies, procedures, workflows, and education to ensure survey readiness and regulatory compliance.

Conducts mock surveys, focused tracers, and unit-based assessments to proactively identify risk and drive readiness improvements.

Oversees regulatory reporting, data submissions, action plans, and evidence tracking using centralized tools and dashboards.

Leads interdisciplinary teams in corrective action planning, and the development of sustainable compliance strategies.

Supports the accreditation of new service lines and sites, ensuring regulatory compliance from planning through activation.

Trains and mentors leaders and frontline staff on survey protocols, documentation standards, and compliance responsibilities.

Oversees regulatory staff and workload distribution, providing leadership, coaching, and performance oversight to ensure efficient department operations.

Collaborates cross-functionally with Quality, Risk Management, Infection Prevention, Nursing, and Medical Staff to align compliance initiatives.

Tracks and reports regulatory findings, improvement actions, and compliance trends to hospital leadership and governance bodies.

Promotes a culture of accountability, transparency, and continuous improvement in accreditation, patient safety, and regulatory compliance.

Facilitates professional development through accreditation workshops and certification support (e.g., HACP) to build internal expertise.

Performs other duties as assigned.
Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area.

Pay Range

$55.40 -$83.09

If you want to use your talents alongside people who face each day with courage and purpose, in an environment that empowers you to do your absolute best, this is where you belong.